04 May EHRs: To Change or Not to Change? Who Should Ask the Question?

“Who the hell is this person who practices medicine in Florida and has never run a health care system?”

That was the complaint attributed to now ousted Veterans Affairs Secretary David Shulkin during discussions regarding the adoption of a new Electronic Health Record system for the VA. According to Politico, negotiations with Cerner corporation had stalled in part, due to the involvement of a well-connected Florida physician who doesn’t like the outdated version of Cerner software in use where he works. Dr. Bruce Moskowitz is reported to be a member of President Donald Trump’s Mar-a-Lago social circle and has been part of regular meetings discussing the pending deal.

Should an offensive lineman be involved in the selection of a new head coach? Should a parent have a say in the naming of a new school board chairman? Should middle managers have input into hiring of the new CEO?

Politics aside, there is a strong argument to be made that all parties should have a representative seat at the evaluation table (how much weight their opinion should carry is another matter!). Former Secretary Shulkin, who was relieved of his duties by President Trump in late March, had been negotiating a contract with Cerner for over a year. Purportedly worth $10 billion dollars, it is considered to be “one of the largest health IT implementations in history” according to Healthcare Informatics. Needless to say, vendors, health IT professionals, and healthcare executives around the country have been keeping their eyes on the VA’s decision…and its decision-making process.

History
The EHR system as we know it has been evolving for over half a century. Since its initial development in the 1960s, it has become ubiquitous in healthcare organizations large and small, but decentralized development has followed different paths leading to challenges in interoperability, quality control of shared patient data, and effective data management. Many healthcare leaders (looking for ways to facilitate data sharing among healthcare networks, give patients more access to their records, and improve the usefulness and efficiency of records systems for providers) are finding themselves facing an uncertain landscape of choices. It’s not easy to replace a whole hospital network’s electronic records system, especially when EHR technology is not fully standardized for interoperable data gathering and sharing.

Choices, Choices, Choices
As health systems begin to consider replacement or adoption of a new EHR system, the questions are many. The propriety of having a “Friend of the President” participate in the VA contracting process aside, who should have a say and which factors should drive EHR consideration?

What primary factors drive healthcare organizations to consider a new EHR?
Dr. Kudler: As a result of the Meaningful Use program, virtually every physician has had experience with electronic medical record technology. Even the most recalcitrant who choose to remain on paper have surely received the computer-generated output. It’s been about 10 years that EHRs have played a central, if not critical, role in healthcare delivery. And, as with computers, cars and smartphones, many organizations are looking at their EHRs as an asset that may be ready for an upgrade. Removing a legacy EHR for a new, hopefully improved, platform is a major (read: daunting) undertaking. Regardless of an entity’s size, those involved in this decision must take a clear-eyed view of the financial, operational, and clinical ramifications.

If financial incentives drove this first era of EHR adoption, there must be equal, if not greater, incentives to make a switch. For example, if an organization has successfully attested to and rewarded for compliance with Meaningful Use, then the rationale for swapping out EHRs must be compelling. Reasons that drive HCOs to change EHRs run the gamut. End-user dissatisfaction, lost revenue, and poor vendor support are just a few. If provider unhappiness is the primary driver, a new EHR is unlikely to justify the investment. Better to save the 10s of millions and invest in comprehensive training and support. However, if the EHR vendor has been unable to keep pace with Meaningful Use, has shown bad faith in the delivery of functionality, is not evolving in the direction of an organization’s strategic goals, then it may well be time to move on.

What factors make an EHR system attractive?
Dr. Kudler: The appeal of a particular EHR system should account for the HCOs needs. A small group of providers may choose to focus on price, regulatory adherence, and ease of use. A hospital would be interested in the ability to transmit, receive and store disparate sets of data, including clinical documentation, radiology and laboratory information, etc. An integrated delivery network would have the same requirements as a standalone hospital, but may also need to account for multiple hospitals, aligned ambulatory practices, and remote ancillary services. Once these business objectives are understood, usability is key, but so is versatility in order to respond to federal reimbursement reform, i.e. MACRA.

Who tends to participate in assessments governing EHR adoption? Whose voices should be involved in the process?
Dr. Kudler: EHR governance is crucial to a successful implementation and forward-going utilization. Participation should be broad and inclusive of all end-user groups. While IT and Clinical Informatics teams “own” the operations of EHR assessment and use, key stakeholders from all corners of an organization should be identified. Members of the C-suite, including CFO, COO, CMO, CNO, and CIO, must also be engaged in this process. Most important are the voices of the providers and nurses who will be using the EHR to deliver safe and effective care.

How should a new EHR be selected? Who makes the final decision?
Dr. Kudler: The governance committee should make the decision with approval from the CEO and board, depending on the HCO.

What’s Next?
How the EHR question at the U.S. Department of Veteran Affairs is answered is anyone’s guess at this point. Whether you agree or disagree with those sitting around the table, the decision-making process can be a lesson for us all.